nosorh 1/08

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Dental Workforce Trends—Opportunities for Rural

Leadership

Shelly Gehshan, M.P.P.National Academy for State Health

PolicyJanuary, 2008

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What I’ll cover

• Overall workforce trends

• What’s happening in states– integrating oral and general health– Changes in scope, supervision

• Progress on new midlevel models

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Is there a Shortage in the US? Active Dentists per 100,000 Population

54.5 54.5

53.3

52

50.7

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50

51

52

53

54

55

2000 2005 2010 2015 2020

4Source: American Dental Association, Survey Center. US Census Bureau (2001).

Is there a shortage? Active Dentists per 100,000 Population (2000)

5Source: Roger Rosenblatt, Holly Andrilla, Thomas Curtin, and Gary Hart. “Shortage of Medical Personnel at Community Health Centers,” Journal of the American Medical Association 295, No. 9 (2006): 1042-10491.

Dentist Vacancy Rates at Health Centers (2004)

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Age Distribution of Private Practice Dentists (2005)

0

5

10

15

20

25

30

35

<35 35-44 45-54 55-64 65+

Source: American Dental Association, 2005

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Is There a Shortage of Hygienists?

• 158,000 hygienists in 2004

• Expected to grow (>27%) by 2014

• Hygienists leave profession

• ADHA says that, due to supervision requirements in many states, hygienists must locate where dentists are, so they are “maldistributed” as well

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212

166161158149150152

145

226

0

50

100

150

200

250

2000

2002

2004

2006

2008

2010

2012

2014

Source: U.S. Department of Labor, Bureau of Labor Statistics, http://www.bls.gov

Number of Employed Dental Hygienists, in thousands

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Dental Safety Net Needs Expanding

• No “dental emergency rooms”• Serves less than 10% of 82 million

underserved people (Bailit, JADA, 2003)

• Critical safety net consists of community health centers, hospitals, dental and hygiene schools, school-based health centers

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What’s Happening in States

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Supply, Redistribution Strategies

• State loan repayment programs for rural DDs and RDHs

• Licensing strategies – Foreign dentists in safety net settings– Licensure by credential– Licensure after service, residency

• Payment incentives (higher Medicaid fees in rural areas, clinics, e.g. Utah)

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Integrating Oral Health into Primary Care

• Dentist to population ratio shrinking; PCP to population ratio is growing

• Prevention is cheaper, better

• More frequent, earlier use of primary care services for young children and underserved

• Patient trust and comfort (fear factor)

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Target Populations for Integrating Oral Health into Primary Care

• Children 0-5

• Adolescents

• Pregnant women

• Special needs children and adults

• Elderly, nursing home residents

• People with chronic diseases, diabetes

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Oral Health Services Medical Professionals Can Provide

• Oral health evaluation (visual screening for decay)

• Application of fluoride varnish

• Patient and parent education

• Dispensing oral health supplies– Toothbrushes, toothpaste, xylitol gum

• Limited prophylaxis, antimicrobials

• Case management, referral

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State Action

• Curricula or training for primary care providers (AL, AR, CA, KY,ME, NH, NV, NY, OR, SD, WA, WI)

• Medicaid payment for MDs to provide fluoride varnish (NC + about 9 others)

• Joint initiatives for screening and referral (SC)

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Trends in dental hygiene

• Gradual loosening of supervision, expansions in scope

• Movement towards providing services in public health settings

• Bulk of hygienists still practice in traditional settings; maldistributed as are dentists

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Supervision and Payment for Hygienists

• General supervision in 45 states in dental office or some settings

• Direct access to patients in some settings in 22 states (AZ, CA, CO, CT, IA, KS, ME, MI, MN, MO, MT, NE, NH, NM, NV, NY, OK, OR, PA, RI,TX, WA)

• Medicaid can reimburse hygienists directly in 12 states (CA, CO, CT, ME, MN, MO, MT, NM, NV, OR, WA, WI)

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What isn’t happening, but needs to

• Disease management approach for dental caries– Caries is infectious, recurs

• Change to primary care model in dentistry – Private practice model organized around

surgery, restorations, maximizing income– Primary dental care would involve screening,

risk assessment, case management, referrals

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Progress on New Provider Models

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Existing Models

• Dental therapist—New Zealand model– Called dental health aid therapist in AK; in use in 53

countries

• Oral health therapist—newer 3-yr program combines dental therapy and hygiene

• Expanded Function Dental Assistants– Underutilized; can expand productivity and profitability

of dental practices– For state licensing, scope info, check:

http://www.danb.org/main/statespecificinfo.asp

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New Models for Dental Providers

• ADA model — Community Dental Health Coordinator (similar to Primary Dental Health Aides

in Alaska)

• ADHA model — Advanced dental hygiene practitioner

• Pediatric Oral Health Therapist (a dental therapist specializing in kids)

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Community Dental Health Coordinator

• Prevention: education, fluorides, sealants

• Treatment: gingival scaling, polishing

• Restoration: atraumatic restorative therapy

• Supervision: direct or indirect for services, general supervision for patient education

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Advanced Dental Hygiene Practitioner

• Prevention: comprehensive services

• Treatment: manage periodontal care, prophylaxis, prescriptions

• Restoration: simple restorations, extractions

• Supervision: general supervision or unsupervised; in collaborative practice, or private dental offices

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Dental therapists

• Prevention: fluoride treatments, sealants

• Treatment: x-rays, prophylaxis, gingival scaling

• Restoration: simple restorations, stainless steel crowns, extractions

• Supervision: general supervision under standing orders

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ADHP DHAT CDHC

Masters level 2-year program 12-18 months

Licensure IHS certification (like licensure)

Certification

Curriculum almost final

In 53 countries Planning

Seeking partners, $, legislation, pilot planned at 2 MN colleges

Proven model, many studies published. Pending legis. bars use in lower 48.

ADA has approved $2 M for 3 pilot projects; pilot ruled illegal in MI

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ADHP DHAT CDHC

True midlevel provider (RDH + 2 yrs)

Function like midlevels, but educated in less time

Close to dental assistant, social worker (not a midlevel)

Post-RDH career track

High school grads

High school grads

Could be supported by reimbursable services

Could be supported by reimbursable services

Supported by grants? Few reimbursable services

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ADHP DHAT CDHC

Pool of RDHs ready to train

Recruited from underserved areas, groups

Not clear, dental assistants?

Risk assessment, case management

Basic preventive and restorative services

Prevention, education, case-finding for dentists

Useful to expand safety net

Useful to expand safety net

Useful for prevention, limited use in safety net

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Cost Effectiveness of Dental Therapists in Canada

• Dental therapists reduced the number of medical evacuations

• Transportation costs dropped dramatically• Dental therapists can deal with most dental

emergencies• Dental therapists make dentists’ visits

more productive, triage patients, take x-rays, arrange for medications before dentist arrives Source: Dr. Todd Hartsfield

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Newtok Clinic, Yukon-Kuskokwim

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AFHCAN CartAlaska Federal Health Care Access Network

• Wireless Networking• Touchscreen• ECG / Video Dental Camera

and Otoscope / Scanner / Digital Camera

• Mobile – Customized• Patient safe

• WWW. AFHCAN.ORG

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How do we move forward on new workforce models?

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Important Steps

• State and local policy communities come to consensus, not national groups

• Focus on the underserved, not providers

• Communicate solutions, don’t assume people understand

• Seek investments from foundations, governments

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Important Partners

• Payors—Medicaid, SCHIP, private insurers, business

• Coalitions—Provider associations, dental/ medical leaders

• Legislators, local and state agency leaders

• Universities, training programs

• Safety net clinics, rural providers

• Foundations

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Ideas for groundwork

• Study impact of midlevels on private dental practice, safety net clinics

• Establish manpower pilot authority (CA)

• Consider new regulatory structure for auxiliaries (WA, NM, IA, CT)

• Target new providers to safety net settings

• Data collection to monitor supply, demand

• Establish multi-state collaboratives

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Why Dentists Oppose Midlevels

• Would create a two-tier system of care

• There’s no shortage of dentists

• It’s illegal for non-dentists to do dentistry

• They would jeopardize patient safety

• Inefficient if they practice independently

• They would take patients away from private dentists

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Dental Economics

• About 45% of patient visits are for hygiene services

• About 55% from insurance, 45% cash

• Very sensitive to downturns in the economy; experience with oversupply

• Overhead averages about $.60-$.65 of each dollar earned

38Source: Albert Guay, “Dental Practice: Prices, Production, and Profit,” JADA, Vol. 136 (March 2005), 359.

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Attitudes about Dentists

• “They feel no obligation to the community.”• “Uncooperative, greedy, lacking in

empathy.”• “The most territorial mammals on the face

of the earth, except maybe dogs.”• “Don’t want to care for poor people but

they don’t want us to either.”

Source: S. Gehshan, T. Straw, “Access to Oral Health Services for Low Income People,” National Conference of State Legislatures, 2002.

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Organized Dentistry Does Care

• “voluntary programs to deliver free care…are no substitute for fixing the Medicaid program.”

• “We need to get more private dentists participating in Medicaid.” (Roth, 3/27/07)

• Active on many issues (SCHIP dental, fluoride, Title VII, dental issues in IHS, CMS)

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Lessons Learned from theMedical Field

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Nurse Practitioners

• Models created by leaders in 1960s (Commonwealth $)

• Nurses opposed them (too medical)

• Studies done on quality, cost effectiveness

• Needed professional home: educational program, faculty leaders (RWJ $)

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Nurse Practitioner Workforce Growth

Source: Unpublished data from the National Organization of Nurse Practitioner Faculties; Analysis by the Center for Health Professions, UCSF, 2004.

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Demonstration programs were mostly rural (RWJ $)

• UC Davis, rural physicians in home towns were clinical preceptors

• Utah Valley Hospital, rural clinics, back-up by ER docs

• Tuskegee Institute, mobile vans, fax/ phone to supervising physicians

• Frontier Nursing Service, KY, rural maternity care, physician back-up

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Elements for Progress

• Demonstrated need

• Workable solutions

• Broad support

• Leadership

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Physician Assistants

• Leader at Duke envisioned PAs as primary care providers, from roots in military medical corps

• National assoc. and accrediting body est’d early on (RWJ $)

• Developed separately from NPs

• Less controversial, yet similar to NPs

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Growth of Physician Assistants 1980-2020

Source: Bureau of Labor Statistics and American Academy of Physician Assistants; Analysis by The Robert Graham Center, 2004.

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Shelly GehshanSenior Program Director

National Academy for State Health Policysgehshan@nashp.org

202-903-0101